Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OUTPATIENT TREATMENT ALLERGY SHOT 1

Facility

$38.00

Service Code	HCPCS 95115
Hospital Charge Code	540197
Hospital Revenue Code	761
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

OUTPATIENT TREATMENT ALLERGY SHOT 2

Facility

$71.00

Service Code	HCPCS 95117
Hospital Charge Code	540198
Hospital Revenue Code	761
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

OUTPATIENT TREATMENT ALLERGY SHOT 2

Facility

$71.00

Service Code	HCPCS 95117
Hospital Charge Code	540198
Hospital Revenue Code	761
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

OUTPATIENT TREATMENT ESRD

Facility

$74.00

Service Code	HCPCS G0257
Hospital Charge Code	540200
Hospital Revenue Code	761
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: BCBS MT CHIP	$66.60
Rate for Payer: BCBS MT Closed Plan Network	$70.30
Rate for Payer: BCBS MT HealthLink	$66.60
Rate for Payer: BCBS MT Medicare	$66.60
Rate for Payer: BCBS MT POS	$70.30
Rate for Payer: BCBS MT Traditional	$74.00
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cigna Commercial	$70.30
Rate for Payer: Cigna Medicare	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

OUTPATIENT TREATMENT ESRD

Facility

$74.00

Service Code	HCPCS G0257
Hospital Charge Code	540200
Hospital Revenue Code	761
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: BCBS MT CHIP	$66.60
Rate for Payer: BCBS MT Closed Plan Network	$70.30
Rate for Payer: BCBS MT HealthLink	$66.60
Rate for Payer: BCBS MT Medicare	$66.60
Rate for Payer: BCBS MT POS	$70.30
Rate for Payer: BCBS MT Traditional	$74.00
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cigna Commercial	$70.30
Rate for Payer: Cigna Medicare	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

OUTPATIENT TRIGGER POINT INJ 1-2 GROUPS

Facility

$440.00

Service Code	HCPCS 20552
Hospital Charge Code	1520552
Hospital Revenue Code	761
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$440.00
Rate for Payer: Aetna Commercial	$418.00
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS MT CHIP	$396.00
Rate for Payer: BCBS MT Closed Plan Network	$418.00
Rate for Payer: BCBS MT HealthLink	$396.00
Rate for Payer: BCBS MT Medicare	$396.00
Rate for Payer: BCBS MT POS	$418.00
Rate for Payer: BCBS MT Traditional	$440.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial	$418.00
Rate for Payer: Cigna Medicare	$396.00
Rate for Payer: Medicaid All Medicaid	$404.80
Rate for Payer: Medicare All Medicare	$308.00
Rate for Payer: Monida Allegiance	$418.00
Rate for Payer: Monida First Choice Health	$426.80
Rate for Payer: Monida Montana Health Co-op	$418.00
Rate for Payer: Monida PacificSource	$418.00

OUTPATIENT TRIGGER POINT INJ 1-2 GROUPS

Facility

$440.00

Service Code	HCPCS 20552
Hospital Charge Code	1520552
Hospital Revenue Code	761
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$440.00
Rate for Payer: Aetna Commercial	$418.00
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS MT CHIP	$396.00
Rate for Payer: BCBS MT Closed Plan Network	$418.00
Rate for Payer: BCBS MT HealthLink	$396.00
Rate for Payer: BCBS MT Medicare	$396.00
Rate for Payer: BCBS MT POS	$418.00
Rate for Payer: BCBS MT Traditional	$440.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial	$418.00
Rate for Payer: Cigna Medicare	$396.00
Rate for Payer: Medicaid All Medicaid	$404.80
Rate for Payer: Medicare All Medicare	$308.00
Rate for Payer: Monida Allegiance	$418.00
Rate for Payer: Monida First Choice Health	$426.80
Rate for Payer: Monida Montana Health Co-op	$418.00
Rate for Payer: Monida PacificSource	$418.00

OUTPATIENT TRIGR PT INJECTION 3+ 20553

Facility

$705.00

Service Code	HCPCS 20553
Hospital Charge Code	520553
Hospital Revenue Code	760
Min. Negotiated Rate	$493.50
Max. Negotiated Rate	$705.00
Rate for Payer: Aetna Commercial	$669.75
Rate for Payer: Aetna Medicare	$634.50
Rate for Payer: BCBS MT CHIP	$634.50
Rate for Payer: BCBS MT Closed Plan Network	$669.75
Rate for Payer: BCBS MT HealthLink	$634.50
Rate for Payer: BCBS MT Medicare	$634.50
Rate for Payer: BCBS MT POS	$669.75
Rate for Payer: BCBS MT Traditional	$705.00
Rate for Payer: Cash Price	$634.50
Rate for Payer: Cigna Commercial	$669.75
Rate for Payer: Cigna Medicare	$634.50
Rate for Payer: Medicaid All Medicaid	$648.60
Rate for Payer: Medicare All Medicare	$493.50
Rate for Payer: Monida Allegiance	$669.75
Rate for Payer: Monida First Choice Health	$683.85
Rate for Payer: Monida Montana Health Co-op	$669.75
Rate for Payer: Monida PacificSource	$669.75

OUTPATIENT TRIGR PT INJECTION 3+ 20553

Facility

$705.00

Service Code	HCPCS 20553
Hospital Charge Code	520553
Hospital Revenue Code	760
Min. Negotiated Rate	$493.50
Max. Negotiated Rate	$705.00
Rate for Payer: Aetna Commercial	$669.75
Rate for Payer: Aetna Medicare	$634.50
Rate for Payer: BCBS MT CHIP	$634.50
Rate for Payer: BCBS MT Closed Plan Network	$669.75
Rate for Payer: BCBS MT HealthLink	$634.50
Rate for Payer: BCBS MT Medicare	$634.50
Rate for Payer: BCBS MT POS	$669.75
Rate for Payer: BCBS MT Traditional	$705.00
Rate for Payer: Cash Price	$634.50
Rate for Payer: Cigna Commercial	$669.75
Rate for Payer: Cigna Medicare	$634.50
Rate for Payer: Medicaid All Medicaid	$648.60
Rate for Payer: Medicare All Medicare	$493.50
Rate for Payer: Monida Allegiance	$669.75
Rate for Payer: Monida First Choice Health	$683.85
Rate for Payer: Monida Montana Health Co-op	$669.75
Rate for Payer: Monida PacificSource	$669.75

OVA & PARASITES EXAM (008623)

Facility

$26.00

Service Code	HCPCS 87177
Hospital Charge Code	4087177
Hospital Revenue Code	300
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

OVA & PARASITES EXAM (008623)

Facility

$26.00

Service Code	HCPCS 87177
Hospital Charge Code	4087177
Hospital Revenue Code	300
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

.OVA & PARASITES STAIN

Facility

$94.00

Service Code	HCPCS 87209
Hospital Charge Code	4087209
Hospital Revenue Code	300
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

.OVA & PARASITES STAIN

Facility

$94.00

Service Code	HCPCS 87209
Hospital Charge Code	4087209
Hospital Revenue Code	300
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

OXACILLIN 10 GRAM VIAL-NF

Facility

$223.00

Service Code	NDC 25021016368
Hospital Charge Code	3007237
Hospital Revenue Code	250
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$223.00
Rate for Payer: Aetna Commercial	$211.85
Rate for Payer: Aetna Medicare	$200.70
Rate for Payer: BCBS MT CHIP	$200.70
Rate for Payer: BCBS MT Closed Plan Network	$211.85
Rate for Payer: BCBS MT HealthLink	$200.70
Rate for Payer: BCBS MT Medicare	$200.70
Rate for Payer: BCBS MT POS	$211.85
Rate for Payer: BCBS MT Traditional	$223.00
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cigna Commercial	$211.85
Rate for Payer: Cigna Medicare	$200.70
Rate for Payer: Medicaid All Medicaid	$205.16
Rate for Payer: Medicare All Medicare	$156.10
Rate for Payer: Monida Allegiance	$211.85
Rate for Payer: Monida First Choice Health	$216.31
Rate for Payer: Monida Montana Health Co-op	$211.85
Rate for Payer: Monida PacificSource	$211.85

OXACILLIN 10 GRAM VIAL-NF

Facility

$223.00

Service Code	NDC 25021016368
Hospital Charge Code	3007237
Hospital Revenue Code	250
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$223.00
Rate for Payer: Aetna Commercial	$211.85
Rate for Payer: Aetna Medicare	$200.70
Rate for Payer: BCBS MT CHIP	$200.70
Rate for Payer: BCBS MT Closed Plan Network	$211.85
Rate for Payer: BCBS MT HealthLink	$200.70
Rate for Payer: BCBS MT Medicare	$200.70
Rate for Payer: BCBS MT POS	$211.85
Rate for Payer: BCBS MT Traditional	$223.00
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cigna Commercial	$211.85
Rate for Payer: Cigna Medicare	$200.70
Rate for Payer: Medicaid All Medicaid	$205.16
Rate for Payer: Medicare All Medicare	$156.10
Rate for Payer: Monida Allegiance	$211.85
Rate for Payer: Monida First Choice Health	$216.31
Rate for Payer: Monida Montana Health Co-op	$211.85
Rate for Payer: Monida PacificSource	$211.85

OXACILLIN 2 GRAM VIAL-NF

Facility

$97.00

Service Code	NDC 64679069901
Hospital Charge Code	3007238
Hospital Revenue Code	250
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$92.15
Rate for Payer: Aetna Medicare	$87.30
Rate for Payer: BCBS MT CHIP	$87.30
Rate for Payer: BCBS MT Closed Plan Network	$92.15
Rate for Payer: BCBS MT HealthLink	$87.30
Rate for Payer: BCBS MT Medicare	$87.30
Rate for Payer: BCBS MT POS	$92.15
Rate for Payer: BCBS MT Traditional	$97.00
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna Commercial	$92.15
Rate for Payer: Cigna Medicare	$87.30
Rate for Payer: Medicaid All Medicaid	$89.24
Rate for Payer: Medicare All Medicare	$67.90
Rate for Payer: Monida Allegiance	$92.15
Rate for Payer: Monida First Choice Health	$94.09
Rate for Payer: Monida Montana Health Co-op	$92.15
Rate for Payer: Monida PacificSource	$92.15

OXACILLIN 2 GRAM VIAL-NF

Facility

$97.00

Service Code	NDC 64679069901
Hospital Charge Code	3007238
Hospital Revenue Code	250
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$92.15
Rate for Payer: Aetna Medicare	$87.30
Rate for Payer: BCBS MT CHIP	$87.30
Rate for Payer: BCBS MT Closed Plan Network	$92.15
Rate for Payer: BCBS MT HealthLink	$87.30
Rate for Payer: BCBS MT Medicare	$87.30
Rate for Payer: BCBS MT POS	$92.15
Rate for Payer: BCBS MT Traditional	$97.00
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna Commercial	$92.15
Rate for Payer: Cigna Medicare	$87.30
Rate for Payer: Medicaid All Medicaid	$89.24
Rate for Payer: Medicare All Medicare	$67.90
Rate for Payer: Monida Allegiance	$92.15
Rate for Payer: Monida First Choice Health	$94.09
Rate for Payer: Monida Montana Health Co-op	$92.15
Rate for Payer: Monida PacificSource	$92.15

OXCARBAZEPINE METABOLITE (716928)

Facility

$53.00

Service Code	HCPCS 80183
Hospital Charge Code	4080183
Hospital Revenue Code	300
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

OXCARBAZEPINE METABOLITE (716928)

Facility

$53.00

Service Code	HCPCS 80183
Hospital Charge Code	4080183
Hospital Revenue Code	300
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

OXYBUTYNIN 5MG ER TAB-NF

Facility

$12.00

Service Code	NDC 63739054833
Hospital Charge Code	3007213
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

OXYBUTYNIN 5MG ER TAB-NF

Facility

$12.00

Service Code	NDC 63739054833
Hospital Charge Code	3007213
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

OXYBUTYNIN TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000369
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

OXYBUTYNIN TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000369
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

OXYCODONE ER TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000370
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

OXYCODONE ER TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000370
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

Know your out-of-pocket cost for care.

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